This Week in Surgery — May 21, 2026

Welcome to This Week in Surgery. This week we're covering 10 notable papers spanning optimizing surgical outcomes, new insights into cancer biology, the future of neuromodulation and genetics, and the culture of surgical training. Let's dive in.

We begin this week with three studies focused on improving patient recovery and outcomes, looking at interventions before, during, and after surgery. The first two come from JAMA Surgery and focus on high-morbidity abdominal operations.

First, looking at preoperative optimization, a large Dutch cohort study evaluated the nationwide implementation of a multimodal prehabilitation program for patients undergoing colorectal cancer surgery [6].

The Study This was a multicenter cohort study across 18 hospitals in the Netherlands. Investigators compared over 1,100 patients who participated in a structured prehabilitation program with a similar number of historical controls from the same centers. The groups were balanced using propensity score matching. The prehabilitation program was comprehensive, including high-intensity exercise three times per week, nutritional support, psychological counseling, and medical optimization for things like anemia and frailty.

Results After matching, the prehabilitation group had a significantly lower rate of overall complications—30 percent versus 38 percent in the control group. This reduction was driven primarily by a drop in medical complications, which occurred in about 15 percent of the prehab group versus nearly 25 percent of controls. Surgical complications were also slightly lower. Furthermore, the median length of hospital stay was one day shorter, and rates of readmission and ICU admission were also reduced. These benefits were seen across all age groups and ASA classifications.

Conclusions The authors conclude that the real-world implementation of a uniform, multimodal prehabilitation program for an unselected colorectal cancer surgery population was associated with a meaningful reduction in complications and length of stay.

Staying with major abdominal surgery, the second paper in JAMA Surgery reports on postoperative recovery following pancreatoduodenectomy, with data from the DIPLOMA-2 randomized trial [5]. This analysis sought to determine if the benefits of a minimally invasive approach extend beyond the hospital stay.

The Study This was a predefined analysis of an international, multicenter RCT. Patients with resectable pancreatic head or periampullary neoplasms were randomized 2-to-1 to either minimally invasive or open pancreatoduodenectomy. To objectively measure recovery, patients wore an activity tracker for two weeks before surgery and for 90 days after. The trackers monitored daily step count, active minutes, and heart rate variability, or HRV, which is a marker of physiological relaxation.

Results Data from 236 patients were analyzed. At 30 days post-op, the minimally invasive group was significantly more active, averaging about 660 more steps and 22 more active minutes per day. They also had a higher heart rate variability, suggesting less physiological stress. While the differences in step count and active minutes disappeared by day 90, the higher HRV in the minimally invasive group persisted. A closer look at the timeline shows the physical activity benefit lasted for about five weeks postoperatively.

Conclusions This trial provides objective evidence that minimally invasive pancreatoduodenectomy is associated with increased physical activity for up to five weeks and reduced physiological stress for up to three months compared to the open approach. The benefits are relatively modest, but they offer a quantifiable advantage in early postoperative recovery.

Rounding out this theme, a study in The British Journal of Surgery provides an economic evaluation of lymphaticovenous anastomosis, or LVA, for treating breast cancer-related lymphedema [10].

The Study This was a pre-specified secondary analysis of a randomized controlled trial that compared LVA combined with complex decongestive therapy, or CDT, to CDT alone. The investigators performed a cost-effectiveness analysis from both a healthcare and a societal perspective over a two-year time horizon, using Quality-Adjusted Life Years, or QALYs, as the primary effectiveness measure.

Results Over two years, the LVA group was more costly from a direct healthcare perspective. However, when viewed from a societal perspective, which includes factors like lost productivity, the cost difference was minimal. The LVA group also gained slightly more QALYs than the CDT-alone group. From the societal viewpoint, the incremental cost-effectiveness ratio was just over 1,700 Euros per QALY gained. At a willingness-to-pay threshold of 20,000 Euros, there was a 60 percent probability that LVA was cost-effective.

Conclusions While LVA adds upfront healthcare costs, it improves quality of life and has the potential to be cost-effective from a broader societal perspective, especially if performed under local anesthesia to reduce costs. This highlights the importance of considering societal benefits when evaluating new surgical technologies.

Next, we turn to two papers that expand our understanding of disease, one uncovering a new mechanism in lung cancer and another reinforcing a surgical indication for a common condition.

First, a study in Cell uncovers a previously unknown neuroimmune axis that promotes lung cancer growth [3].

The Study Investigators studied the role of sensory innervation in lung adenocarcinoma. They found that as tumors progress, they locally amplify nociceptive, or pain-sensing, sensory nerves. Activation of these nerves leads to the release of the neuropeptide CGRP.

Results The released CGRP acts on a subset of macrophages, which in turn impairs the recruitment of fibroblasts needed to build tertiary lymphoid structures, or TLS. These structures are critical hubs for anti-tumor immunity, and their absence is a poor prognostic sign. Essentially, the pain nerves were suppressing the local immune response. The study also found that cigarette smoke extract activates this neural circuit, providing a non-mutagenic mechanism by which smoking promotes lung cancer. Critically, local sensory denervation or pharmacologic blockade of CGRP restored TLS formation, enhanced anti-tumor immunity, and suppressed tumor growth. In animal models, CGRP blockade also sensitized tumors to immunotherapy.

Conclusions This work identifies a direct link between nociceptive neurons, neurogenic inflammation, and impaired anti-tumor immunity in lung cancer. It suggests that targeting the CGRP pathway could be a novel strategy to overcome immune resistance, particularly in smoking-related lung cancer.

From basic science to clinical practice, a multicenter study in Surgical Endoscopy provides strong evidence for an underrecognized indication for paraesophageal hernia repair [7].

The Study This retrospective study investigated whether surgical repair of a paraesophageal hernia, or PEH, could resolve unexplained iron deficiency anemia. The researchers analyzed data from 1,700 patients undergoing hiatal hernia repair. They focused on a group of 136 patients who had unexplained anemia, after excluding anyone with obvious bleeding sources like Cameron lesions or ulcers. This anemic group was propensity-matched to 297 non-anemic controls.

Results The results were striking. At 12 months after surgery, anemia had resolved in 93 percent of the patients. The mean hemoglobin increased by 3.2 grams per deciliter, and ferritin levels normalized. Iron supplementation was successfully stopped in over 80 percent of patients. Notably, this resolution was durable; even among the 16 patients who had an anatomical hernia recurrence, 75 percent of them remained non-anemic.

Conclusions For patients with a paraesophageal hernia and unexplained, refractory iron deficiency anemia, surgical repair appears to be a highly effective treatment. The authors suggest that PEH repair should be strongly considered for this specific indication, warranting prospective trials to establish formal guidelines.

Looking toward the future, two papers highlight the growing roles of genetics in risk stratification and non-invasive neuromodulation in treating movement disorders.

First, a massive study in Nature Medicine details the cancer risks associated with germline genetic variants found in pediatric patients [2].

The Study Investigators analyzed exome sequencing data from over 75,000 pediatric patients who were referred for genetic testing for a variety of reasons, most commonly neurological or metabolic symptoms. They tracked cancer as a secondary finding, looking for germline pathogenic or likely pathogenic variants, known as P/LP variants, in 139 known tumor susceptibility genes.

Results Among the more than 64,000 patients without a pre-existing tumor, prospective follow-up revealed a dramatically higher incidence of malignant tumors in children carrying P/LP variants. Their cancer incidence was 3.23 per 1,000 person-years. This was more than ten times higher than the incidence in children with variants of uncertain significance or other variants, which was around 0.25 per 1,000 person-years. Among all children in the cohort who developed tumors, nearly one-third harbored one of these causative germline variants.

Conclusions These findings underscore the critical importance of identifying these P/LP variants. When pediatric patients undergo genetic testing for any reason, a secondary finding of a P/LP variant in a cancer gene confers a substantial future cancer risk, necessitating proactive genetic counseling and long-term surveillance.

Moving from genetics to neuromodulation, a paper in Science Translational Medicine explores the use of transcranial ultrasound stimulation, or TUS, for Parkinson's disease [4].

The Study This study aimed to provide mechanistic evidence that TUS, a non-invasive technique, can precisely modulate deep brain circuits. Researchers studied 17 patients with Parkinson's disease who already had deep brain stimulation electrodes implanted in their subthalamic nucleus, or STN. This allowed for direct measurement of neural activity while TUS was applied to different targets, including the primary motor cortex (M1) and the globus pallidus internus (GPi).

Results The effects were target-specific. When TUS was aimed at the M1 motor cortex, it successfully reduced pathological beta oscillation activity in the deep-seated STN. This reduction in beta waves was associated with an improvement in the patients' motor signs. In contrast, when TUS was aimed at the GPi, it actually increased beta activity and did not improve motor signs.

Conclusions This study provides direct electrophysiological evidence that non-invasive transcranial ultrasound can safely and selectively modulate pathological brain rhythms in deep brain targets. It supports the potential of TUS as a targeted, non-invasive therapeutic modality for conditions like Parkinson's disease.

Finally, we look at the broader context of our profession, from the culture of surgical training to a primer on a common comorbidity and a new clinical practice guideline.

A study in the Journal of the American College of Surgeons explores why pregnant and parenting residents continue to face challenges despite the presence of accommodation policies [9].

The Study This was a six-month ethnographic study conducted across two general surgery and two internal medicine residency programs. Through observations, focus groups, and interviews, the researchers examined program culture and the use of work-life accommodations.

Results The study identified a pervasive 'flexibility stigma.' This is a bias against individuals who use accommodations, which are often perceived as signaling a reduced commitment to the ideal of a self-sacrificing, constantly available resident. This stigma creates a 'double bind,' forcing trainees into impossible choices between their professional duties and essential personal needs like parenting, maintaining a healthy pregnancy, or basic self-care. The fear of reputational harm led many to forgo accommodations, with negative consequences for their well-being. The authors note that program-level factors, such as staffing models and leadership behavior, could either intensify or mitigate these pressures.

Conclusions Flexibility stigma is a structural barrier that undermines existing support policies. To truly support trainee well-being and advance equity, programs must address not only policies but also the underlying cultural norms and program design that create these pressures.

Also this week, Nature Reviews Disease Primers published a comprehensive overview of tinnitus, the perception of sound without an external source [1]. This condition affects roughly one in seven adults and can be severe for about 2 percent of them. The primer covers the complex pathophysiology, which involves cochlear injury triggering maladaptive plasticity in the central nervous system. It also reviews management strategies, emphasizing that first-line treatments are tinnitus-focused counseling and cognitive behavioral therapy, with hearing aids and neuromodulation as valuable adjuncts. This is a useful resource for surgeons who may encounter patients with this common and often distressing comorbidity.

Lastly, we note the publication of a new Clinical Practice Guideline for the Surgical Management of Ulcerative Colitis in Diseases of the Colon and Rectum [8]. The abstract was not available for review in this week's feed, but surgeons who manage IBD should be aware of this new resource from the American Society of Colon and Rectal Surgeons.

If you only have time for one paper this week, make it the study on multimodal prehabilitation for colorectal cancer in JAMA Surgery [6]. This large, nationwide study provides strong, real-world evidence that a structured pre-op program significantly reduces complications and hospital stay, offering a clear, high-impact intervention that can be implemented now.

Here are the key takeaways from this week in Surgery.

First, consider implementing a multimodal prehabilitation program for your colorectal cancer patients. A large Dutch study showed it reduces overall complications and shortens hospital stays [6].

Second, for patients with a paraesophageal hernia and unexplained, refractory iron deficiency anemia, surgical repair is highly effective, resolving anemia in over 90 percent of cases [7]. This should be considered a strong indication for surgery.

Third, minimally invasive pancreatoduodenectomy appears to offer a real, if modest, benefit in early postoperative recovery, with patients showing more physical activity and less physiological stress for up to a month compared to open surgery [5].

Fourth, in pediatric patients found to have pathogenic germline variants in cancer susceptibility genes for any reason, be aware of their substantially increased cancer risk and ensure they receive appropriate counseling and surveillance [2].

Finally, as leaders and educators, we must address the 'flexibility stigma' in residency. Merely having policies for parental leave is not enough; we need to actively change program culture to support trainees' well-being and family formation [9].

That's your roundup for This Week in Surgery. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.